Personal Care Management Prior Authorization Processing Specialist

Summary/Objective: The position of Prior Authorization Specialist is a role that requires in depth knowledge of the PCA program rules and regulations, and Standard Operating Procedures of the Optum/MassHealth Prior Authorization Unit (PAU).  This position requires daily management of submission of MassHealth Evals for the PCA program in a timely manner, with proper prioritization to prevent a PA Extension.  Thie role will provide consistent follow-up with the PA dept staff, Quality Assurance/Document Imagine, PCM Skills Trainer leadership to obtain completed documents, and PCM Eval department documents.   Must be effective in delivering consistent results, maintain a high level of knowledge of all tasks within the department, and able to work effectively with accuracy in data input.

Essential Functions    


* Follow PCA Program requirements, MassHealth rules, contracts, and PAU standards.


* Track PAs that will expire within 31 days and take appropriate action.



* Manage PA requests, including new requests, extensions, deferrals, adjustments, and resubmissions.


* Review PAs to make sure all information and required documents are complete and accurate.


* Identify missing or incorrect information and follow up to get the needed documents.


* Identify PAs that need clinical review or adjustments.


* Work with nursing/clinical staff to obtain required documentation and physician signatures.


* Submit and track PA adjustments until they are resolved.


* Follow up on deferrals and resubmit requested information within the required timeframe.


* Process PA extensions according to MassHealth and PCM requirements.



* Process deferrals through resolution, including obtaining requested information, resubmitting documentation within required timeframes, and monitoring outcomes.


* Process extensions in accordance with MassHealth requirements and PCM procedures, including identifying the reason for the extension and ensuring appropriate documentation is submitted.


* Review and appropriately escalate extensions exceeding 90 days to PCM leadership, including providing rationale and supporting information.


* Monitor PA status and proactively address pending, expiring, denied, deferred, or otherwise unresolved authorizations to prevent service interruptions.


* Process Transition of Care Prior Authorizations for consumers transitioning from Integrated Care to Fee-for-Service, ensuring all required information is obtained and processed timely.


* Communicate directly with MassHealth PAU and PCM leadership to clarify complex, unusual, or uncertain processes and resolve authorization-related issues.


* Work effectively in a hybrid work environment, maintaining productivity, communication, availability, and service standards while working remotely and onsite as required by departmental and business needs.


* Perform other duties and responsibilities as assigned.


* All other...